Healthcare Provider Details

I. General information

NPI: 1467319202
Provider Name (Legal Business Name): SOPHANAROTH PENH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 BOXWOOD ST
WILLISTON VT
05495-8211
US

IV. Provider business mailing address

11 PARK ST UNIT 415
ESSEX JUNCTION VT
05452-4175
US

V. Phone/Fax

Practice location:
  • Phone: 802-878-9056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number033.0135925
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH1002621
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: